Provider Demographics
NPI:1922218668
Name:YAMAMOTO, LESLIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:YAMAMOTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4715
Mailing Address - Country:US
Mailing Address - Phone:907-455-4135
Mailing Address - Fax:907-455-4105
Practice Address - Street 1:407 5TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4715
Practice Address - Country:US
Practice Address - Phone:907-455-4135
Practice Address - Fax:907-455-4105
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK401104100000X
AK8541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker